# Tuberculosis diagnosis and the complete drug resistance pattern from a single sample within a single day by use of a composite platform of MAX MDR-TB and AmPORE-TB

## TL;DR

A new platform combines two tests to diagnose tuberculosis and determine drug resistance from a single sample in one day, improving treatment speed and outcomes.

## Contribution

Introduces a one-day diagnostic platform integrating BD MAX MDR-TB and AmPORE-TB tNGS for rapid TB diagnosis and drug resistance profiling.

## Key findings

- The platform achieved a final result in 8.5 hours with 85.1% sensitivity for spiked samples and 73% for clinical samples.
- Resistance profiling failed most frequently for clofazimine, pretomanid, and delamanid in both spiked and clinical samples.
- The platform reduces the need for multiple sputum samples and clinic visits, potentially lowering transmission and drop-out rates.

## Abstract

Rapid TB diagnostics are essential for effective TB control. Combining WHO-recommended rapid molecular tests with downstream targeted next-generation sequencing (tNGS) enables faster drug resistance profiling. The objective of this study was to establish a one-day diagnostic platform (ODDP) integrating BD MAX MDR-TB and AmPORE-TB tNGS from a single sample. Pooled sputum samples spiked with 52 pre-characterized Mycobacterium tuberculosis (MTB) strains and 74 MTB-positive clinical samples were tested using BD MAX MDR-TB for TB, isoniazid, and rifampicin resistance. tNGS was performed from 5 µL of purified DNA leftover for each TB-positive sample in the BD MAX strips. IS6110/IS1081 Ct-values served as surrogate markers for TB DNA concentration. A total of 104 spiked and 60 clinical samples tested positive by BD MAX. The average time to the final ODDP result was 8.5 h. For samples with Ct ≤28, tNGS generated antibiotic resistance profiles for ≥12 antibiotics with 85.1% sensitivity in spiked and 73% in clinical samples. Failure rates were 10% and 8.3%, respectively. Resistance profiling most frequently (up to 11.3%) failed for clofazimine, pretomanid, and delamanid. The ODDP enables comprehensive TB diagnosis and resistance profiling from a single sample in 1 day. This platform can significantly accelerate the time to informed drug-resistant (DR)-TB treatment decisions.

Reducing the time to treatment initiation decreases patient drop-out rates, morbidity, the emergence of new drug resistances, and onward transmission of infection. Obtaining the complete resistome from the start is crucial for choosing a fully effective treatment regimen. Until now, diagnosis with full resistance profiling has required at least two sputum samples and 3 to 7 days for the complete workflow, obliging patients to return two to three times, which dramatically increased the risk of loss to follow-up. Our one-day diagnostic platform enables both diagnosis and comprehensive resistance testing from a single sample within 1 day. Patients can remain in a day clinic during testing and receive a fully effective, individualized treatment regimen the same day. This approach is expected to markedly reduce morbidity, drop-out rates, and transmission. The necessary instruments and technologies are already available in many high-prevalence countries and are currently being rapidly scaled up worldwide.